Harvard School of Public Health | Alan M. Garber, Provost of

BETTY Good afternoon, and welcome to the Voices in Leadership series. This program focuses on the nexus of science JOHNSON: and leadership to create positive change in the world of public health. I am Betty Johnson, and I have the privilege to direct and introduce this program.

Our guest today could be called a Renaissance man of academia. When he was a university freshman, he said, and I quote, "I was a reluctant and ambivalent pre-med student. But after being exposed to an economics course, I switched my major to a concentration from biochemistry to economics," end quote.

This switch in plan ultimately led to a PhD in economics from Harvard, while at the same time he was earning an MD degree from Stanford. Today, Dr. Alan Garber's career combines both interests. And it is no surprise that this combination of a love for science and economics eventually landed him a role as university provost.

But not as any university provost, our university provost. In a political climate in Washington, DC, where robust research funded is under threat, Dr. Alan Garber is perfectly suited to lead Harvard's efforts to ensure the

research pipeline remains strong. His intellectual interests are far reaching.

At Stanford, he was a fellow in both the Freeman Spogli Institute for International Studies and the Stanford Institute for Economic Policy Research. He also served as director for Stanford Center for Health Policy and Center for Primary Care and Outcomes Research at Stanford School of Medicine. Dr. Garber brings an economist's perspective to questions of health policy and focuses his own research on ways to improve health care quality, delivery, and interventions.

He has authored or co-authored more than 125 articles, and edited or co-edited eight books on health policy research. The recipient of numerous academic awards, he has been elected to membership in the American Society for Clinical Investigation, the Institute of Medicine of the National Economy of Sciences, the Association of American Physicians, and a fellow of the Royal College of Physicians.

And if this is not enough to keep him busy, Dr. Garber loves new technology and considers digital learning as woven into the pedagogical fabric of the university. When he isn't exploring new gadgets, he can be found in a swimming pool, where he has become quite an accomplished aqua jogger.

Before I turn this session over to Dr. Bob Blendon, Senior Associate Dean for Policy Translation and Leadership Development here at the school, and who will conduct today's interview, please join me as we welcome Dr. Alan Garber to the Voices in Leadership series at the Harvard T.H. Chan School of Public Health. Thank you.

[APPLAUSE]

ROBERT J. Betty, thank you very much. Before we start with Dr. Garber, I always thank the students. This idea for this series BLENDON: is a student generated idea. And what was the concern?

The concern was you are exposed worldwide that people who make leadership decisions, they're different than we are or talk about in our classrooms. And people wanted to know how do they think about it? How do they make the decisions? What do they draw on? Are there any lessons for this? To be quite honest, a lot of people at Harvard hope to be sitting where Dr. Garber is at somewhere in their life. So is there things and insights that we can bring?

So that's what this series is, and we have tried to be responsive. So my struggle is to ask just a small number of very general questions that gets him to really talk about more broadly. So we have two stages here.

One is, he did start at a section that not every physician decided to be an economist. That may have changed over the years. So tell us, Alan, how you made the decision of putting the two together and what did it look like at that time versus this time. What did you see your role in academics, in medicine, when you put the two together?

ALAN M. Well, thank you, Bob. And thank you, Betty, for that very generous introduction. I think Betty gave a great GARBER: capsule explanation, but maybe I'll expand on this just a little bit. I came and, as she mentioned, started out as a biochemistry major. Biochemical sciences concentrator, as it's called at Harvard.

And I took EC10, the introductory economics course which almost everybody took back then. When I say almost everybody, there were 900 other undergraduates in the class. The size of a class at the time was around 1,600. So more than half of all the students took the course.

And I discovered I loved it. But I still took a heavy science load and took this one economics course. And I thought the issues that economists were grappling with were truly compelling issues. And my second year, I moved into one of the residential houses, , and the resident tutor in economics convinced me that if I loved economics that much, I should actually study it.

That is, make it my concentration. And so he ended up convincing me to switch to economics and gave me advice, including become a research assistant for a faculty member. And I did. Dick Freeman, who's still on the faculty, a labor economist.

And as time went on, I was thinking, I thought I'd probably want to become a physician. And I was still thinking that. But I got more and more deeply involved in economics, and I started taking graduate courses. And at some point, I had to make a decision about what I would do after college.

And I went around and spoke to various people around Harvard. I went to some economists and said, I think I'm interested in health policy issues and would like to think about population level health and so on. And the economists said, well, you should definitely get a PhD in economics, then. It's the best set of tools.

I went to physicians. People on our medical faculty said, you should definitely get an MD. That's the best way to approach it. I went to the then dean of the School of Public Health who said you should get a doctorate in public health, because it combines all these skills.

ROBERT J. Perfectly logical. BLENDON:

ALAN M. However, some of the faculty, I spent more time with than the others. And that's the economics faculty. I was in GARBER: their midst because I was working as a research assistant. And I thought I would probably get a PhD in economics, but I did have one nagging doubt. Which was, as you all know, economists use highly stylized models, make various kinds of assumptions. And my nagging doubt was would the work I did really be useful, would I make unrealistic assumptions. Could I really know what I was doing.

And the other thing is I ultimately decide, yeah, I really do want to take care of patients. So I decided to combine the two fields. And you asked was that unusual. At the time, as far as I knew-- and this is still true-- at the time, there were only two people who were either in the process of getting or had gotten MDs and PhDs in economics.

Both at the time were here. One of them was a faculty member at MIT who had been a Harvard undergrad, got an MD/PhD at Penn. The other was, I think, finishing up his combination of MD and PhD at MIT and . And they were fairly encouraging about getting the two degrees.

Now, let me add. I was very concerned about a series of policy issues. People were worried at the time about un- insurance. And health care costs seem to be rising at an unsustainable rate. By the time I graduated college, health expenditures had reached 8% GDP after this period of continuous rise.

Well, as you all know, we're at about 18% today. So I was correct that health expenditures would rise. I had a misconception about how high they could go. But I knew this was something I wanted to work on. And so that's how I ended up in the field.

And I have to say that the curricular choices today are much greater. There are many more programs for people who have interests like mine. But one thing that any student should keep in mind is that it's not so much about what's the optimal program in general. It's what matches your interests and what will really excite you.

And I was completely taken with the economic approach to modeling. And for most of my career, what I've basically done is apply economic tools to problems of health care and health policy.

ROBERT J. So when you took your first academic role, strategically, what did you see this joint focus? How did you see this BLENDON: playing? Medical schools and economics departments were not instantly related, as I recall. And how did you think about the role you would play between two schools, two fields. Or did it just come naturally?

ALAN M. Well, it came pretty naturally. I had to get my PhD at Harvard because I had taken enough courses that if I went GARBER: anywhere else, it would've taken at least an extra year. But I was thinking about going to Stanford for medical school.

And when I was admitted, they arranged for me to get in touch with two members of their faculty who happened to be two of the leading health economists in the world. Alain Enthoven, who was the father of managed competition, and Victor Fuchs.

And so the question was should I do this combination. That was still a live question in some ways. And Alain said, this is great. This is the perfect preparation for someone who wants to deal with big health policy issues of our time. And Vic was quite skeptical, actually.

He said, well, let's think about-- you know Vic personally, and I'm sure many people who are listening in know him or know of him. And he said, if you want to take care of patients, I see why you would get an MD. But then why would you get a PhD? And he said, if you want to do economics, then get the PhD. But then why would you spend all the time getting your MD? Now, he was using the concept of opportunity cost, thinking about the extra time it took. And I did not know opportunity cost until I did my dissertation in my residency.

But he was raising some very valid points. And then I thought about a bit, and I said, well, I do want to take care of patients. And as for the PhD, I only have one more year of course work to do. And I think I'll do that no matter what.

And I viewed the dissertation as consumption, because I want to do the research anyway. This is pure consumption. And he said, oh, OK. Well, that makes perfect sense. Only an economist would think writing an economics PhD thesis could be consumption.

But anyway, that at least persuaded him. And so I had their blessing. And I ended up going to Stanford for med school and working on my dissertation while I was out there. But maybe the more interesting aspect of your question to answer is what this meant in terms of how I thought about applying these tools later.

ROBERT J. Right. BLENDON:

ALAN M. And so I'll have to admit, this goes back to the late '70s. That's when I started this combined program. And at the GARBER: time, people had ways of thinking about the major health care and health policy problems that you would think of today as quite primitive.

And the use of quantitative tools, for example. The use of data to think about problems. And my dissertation was actually on antibiotic resistance. Not your standard economics topic. But the issue, as many of you will instantly recognize, is that as long as antibiotic resistance is a real phenomena, it means if I take an antibiotic, I raise the risk that you will get an antibiotic resistant infection.

And at the time, there was a controversy over the use of antibiotics in animal feeds. That has not died out altogether, as you all know. And I thought I could use economic tools to analyze this problem, look at the cost, and help inform debates about what's the best policy to handle this problem.

For example, should there be restrictions on prescription of antibiotics in the outpatient setting, or should there be policies to restrict antibiotics in animal feed, which the FDA was actually considering at the time. And this was an ideal set of tools, I believe, to address a problem like that.

ROBERT J. So I have to move when I feel from the audience this underlying question. Ask him, Bob, how he got from this to BLENDON: worrying about the future of the universities. So how did we make the transition in your own mind from this career, which was joining with medicine and economics, to starting to think about an administrative role which has a lot to do with the future of major universities.

I know it was logical to you. It's just there's a line that's missing here that--

ALAN M. No, Bob, it was not logical at all. It was actually, in many ways, a series of happenstances. So I had a very GARBER: enjoyable career as a researcher. I ended up running two centers at Stanford. And I assiduously tried to avoid taking on any administrative responsibilities beyond those that were associated with running the centers,

because I loved the work. I also loved nurturing and mentoring young faculty and students. So for most of my time at Stanford, I was running a fellowship program that was primarily a postdoctoral fellowship program. And I happened to start running it almost by accident about three years after I started as an assistant professor.

And it's not something I would recommend. But opportunities don't always look like opportunities, nor can you control the timing. But that turned out to be a source of incredible satisfaction. But just by being around, I served on various committees. And one of them was Stanford has this committee that makes the final decisions on all faculty appointments and promotions for the entire university. And it meets weekly.

And it's a huge amount of work because it's a lot of faculty appointments and promotions. And much to my surprise-- and you don't volunteer to serve on this committee, by the way. You get elected. And then you can't really say no.

So I was not looking out to do something like that. And much to my surprise, I found it utterly fascinating. And I thought it was probably the most worthwhile committee I'd ever been on. And it's because you get exposed to work at the forefront of every field that's represented in the university.

And typically people, when they're coming up for tenure, anyway, who are beginning the peak period of their careers and they're at the cutting edge of every field, and it's impossible not to be interested in that kind of work. So that was a clue, actually, that I might be interested someday in being a provost. But nevertheless, I kept avoiding any kind of additional responsibility.

And then I happened to end up serving on the visiting committee for the medical and dental schools here. So for those of you who are not familiar with the visiting committees, they're external review committees for the different academic units in the university. And I found out a lot about Harvard Med School and the School of Dental Medicine by that means. Got to know the university from a distance, but up close, in a way, at the same time.

And eventually when the position of provost opened up, I did not really have an interest in it. But I had met with President Faust to discuss how this might be used to address some of the challenges facing Harvard University. And I came to the conclusion she'd be a fantastic person to work with in any capacity.

And I also saw the flaws of Harvard as a university and some of the incredible opportunities. And I happened to be at a stage in my career where I was less interested in continuing to do what I'd been doing because I could make incremental progress. But it happened to be at a right stage. And it was totally outside my conscious recognition.

And I would not have pursued this had the opportunity not just arisen. So nothing about this was planned, to tell you the truth. But in retrospect--

ROBERT J. Of course, that isn't what we teach. But that's a different story. BLENDON:

ALAN M. That's right. Well, sorry, Bob. But sometimes things happen serendipitously. But I do have to say that just by GARBER: chance, so much of what I did turned out to have prepared me for this kind of career. So cynical department chairs and mentors for students and mentors of graduate students will give advice such as no good deed goes unpunished. They'll offer you condolences if you're drafted to serve on a committee. But that's wrong.

It's wrong that you will be punished. And it's wrong that it will not be satisfying to you, because most people who are in an academic community that they care about, if they find that their skills are being well used, it's a very gratifying experience.

So it doesn't mean that every kind of service is identical. But it can be very, very satisfying when you get a sense of helping build a community and helping to change the future of your institution. And I don't think that's unique to people who are aiming toward leadership. It's part of being a member of a community and caring about its future.

ROBERT J. So we're going to switch, as you and I talked about, about some of the major issues that face the university in the BLENDON: future. But before, we need a line or two. If you're from other universities, they have provosts but they do different roles.

So I thought we just would get a quick summary. How is the role established here, what share of the future of the university are you responsible for, what are the priorities. Because it differs in each university.

ALAN M. So the provost position at Harvard has existed since the early '90s. And I mean 1990s, by the way. Not 1890s, GARBER: not 1790s, and not 1690s. So it's relatively new compared to the provost role at our peer institutions and most other universities in the country. And it's evolved over that time.

So I'm only the fifth provost in modern times. There was actually briefly a provost after World War II in a kind of unique circumstance. But there was no continuity beyond that. And it has actually evolved into something that's more similar to provost roles in other universities.

So the provost is the chief academic officer responsible for academic oversight of the schools, and very involved in tenure decisions. Drew and I are responsible for all tenure decisions, although she has the final word on tenure decisions. But there are some things that are a little unusual here.

Every inner faculty initiative reports to the provost at Harvard. So the inner faculty initiatives refer to interdisciplinary centers and institutes that cross schools. So some of these are jointly administered with schools, including the School of Public Health. And some just report solely to the provost's office.

The affiliates report to the provost's office. So that includes the , which of course is the largest university library in the world. It includes the ART, the American Repertory Theatre. The Nieman Fellows program. It includes the , which is one of the largest arm museums of any kind in the country.

So that's a little different from most other provost roles. And one thing that maybe not everybody knows about, we do have a place called , which is Bernard Berenson's estate in Florence. And it's a Renaissance study center. And here is a Harvard trivia observation. This is the place where Harvard produces olive oil and wine.

ROBERT J. If there's a joint program available, please let us know.

BLENDON: ALAN M. But more seriously, the substance of what I do, and one of the reasons why I thought I might be able to GARBER: contribute to the academic life of the university, is to try to reduce barriers across the different parts of the university. So when I had spoken with Drew in the past about Harvard's strengths and weaknesses, I had made the comment, as a Stanford faculty member who knew Harvard reasonably well, that Harvard had unbelievable human resources.

The students and the faculty and the staff superb. At a level that other institutions could really only dream of, in some ways. And it's not just a matter of quality. The quality was there, of course, in scale.

But the different parts of the university didn't always work together well. And I was at an institution, Stanford, where the different parts did work together well. I saw this as a solvable problem. And I was excited by the notion that as provost, one could do something to really improve the situation.

Now, I realized when I came here, I am a general internist. I thought that I was facing a surgical problem, and then I discovered it was more of a general internal medicine problem, i.e. managing chronic disease. However, we've made progress. And it's not because of my office and me alone.

There's many, many people throughout the university who want to make the university work together this way, who want to work across boundaries. But we have a concerted effort to improve that. And I have to add that when I interviewed for this position, it was a group interview. So there was a line of people on one side of the table, a line of people on the other.

And somebody over here said, it's just impossible to work across schools. And somebody over here said, we do it all the time, no problem. So clearly people have very different experiences in this institution. And a lot of the solution to this problem may just rest with finding best practices, finding out what works, and then imitating them, copying them in other settings.

ROBERT J. So in what is a very short time, a sense of what the four or five big issues that you see facing the university. The BLENDON: beauty is you inherited an incredible worldwide institution. At the same time, it faces a number of changes and challenges. And how do you think about them? And then the question is, how do you get some help or advice or think our way through that?

ALAN M. So the biggest challenges, I would say that the number one challenge for Harvard is true for other universities, GARBER: which is to position ourselves to offer the absolutely best education in the future. And at the same time, to assure excellence in research going forward. And they're linked, but they're somewhat separate issues.

And as many of you know, I've been deeply involved in online education. I co-chair the board of edX, and we had started edX as a result of conversations the we initiated with MIT shortly after I arrived here. And why did we get into online education?

We thought this was an opportunity to make available the wonderful teaching of Harvard faculty to people throughout the world. So that was one motivation. But we also thought that these new tools, these new technologies, would make it possible for us to explore how we teach and how we learn in a different way than we had before. Now, this is not all about technology. This is partly about provoking new conversations on campus, among our faculty and also among our students, about how we teach and how we learn. And we found from the very beginning of starting HarvardX-- which is the Harvard part of edX, if you want to look at it that way, but it's actually broader than that-- that people change how they think about teaching and learning. Even faculty who have taught courses for many years, including one of our first courses, was a School of Public Health course on epidemiology and bio-statistics.

People approach their teaching in new ways. So we knew, actually, from the experience at other places and at Harvard with online learning that preceded this that going through this forced faculty to reexamine how they teach. So I think we have succeeded in opening up a new discussion on campus.

And I think we've also developed more and more tools to help people think about teaching, change their experiment with new approaches to teaching. And furthermore, to conduct research so that we know whether these teaching innovations are actually improving learning. So I would put that right up there.

Second, on the research. We're at a time, as I think everyone knows, of diminishing federal support for research, the kind that we conduct. And it's a time of this strange combination of some pessimism about the funding and optimism about what we can do with science today. And the scientific opportunities, especially in the life sciences, have never been greater. And there's huge potential.

So at Harvard and at other institutions, we've been thinking very, very hard about what we do to ensure our strengths in conducting research into the future. We can't let these opportunities pass by. And as part of this, as many of you know, we have conducted a life sciences review based in the schools, the School of Public Health did one. The medical school and the faculty of arts and sciences, and then a university wide life sciences review.

And we expect to get the reports out later this month or early next month. Why did we do this? It gets back to what I said before about some of the problems we have as a university and some of our strengths. That is to say, we have a scale and quality that are unmatched, but the different pieces don't always interact in the most productive way possible.

That's a huge opportunity if we can improve that. So we brought in these very distinguished outside reviewers who confirmed that. And they told us that they were overwhelmed by the quality of our life sciences and by the complexity of our organization. So we have something to work on, and you'll hear more about this. But the life sciences is only one area of our research activity, but it's a huge part of what we do as a university.

A third thing I would add that is a focus for us is Allston. And as some people who are listening in may not know what Allston is. But it's an area of Boston across the river from Cambridge where is located. And we have a lot of property there that's available for us to develop for academic and other uses.

I view this is an opportunity unlike any other in academia in the United States because we have not quite a blank slate, but a lot of land that can be developed into totally new conceptions of academic space, of maybe innovation, knowledge related industries, in continuity with the academic space with a lot of opportunities to think about interactions. And thinking about doing things in a new way in general. So as many people know, we are in the latter stages of planning the science and engineering building where much of the School of Engineering and Applied Sciences will be housed. But we're also thinking about what happens after. And one of the reasons I want to just say why I think Allston is so exciting is it's just across-- this area extends over to Boston University, and it's very large area.

And we have a 36 acre site that's designated as an enterprise research campus. That area is large compared to, say, Kendall Square. With Kendall Square in Cambridge has this huge concentration of life sciences firms, technology firms, and so on. And Kendall Square is pretty well built up. There's not much more space that can be developed there.

Kendall Square is 30 acres. We have 36 acres to be developed here. And the possibility of a light rail link between our property in Allston and Kendall Square. We see this as an opportunity for the Boston region to continue to grow the innovation related industries and take advantage of this incredible environment with the universities, this educated workforce, the hospitals, the existing industries.

This is a place unlike any other. And to have this land where it's situated means we have a huge opportunity to benefit from what exists and to reinforce, to add to what we have here. And I think that will help cement Boston's position as a leading area for innovation.

ROBERT J. So this is different than you worked on earlier in your career. So how do you make the transition to thinking about BLENDON: this issue from what you did before? Are there outside people that are advice. You visit lots of universities. This is a very broad strategy, but it's a different way about thinking about it.

ALAN M. Well, that's right. So first point I would make is remember that I spent 25 years on Stanford's faculty, which GARBER: meant I was in Silicon Valley. So these ideas were not new. But there's another point that I think you're drawing out, which is how do you think about these massive opportunities?

How do you engage with people? How can you be effective at moving the ball forward on something big like this? And one of the things that people need to recognize is a leader of the university is much more like the mayor of a city than like the CEO of a corporation.

You have to get out and know your community, hear from the community, and provide some guidance. But the greatest ideas come from our community. We are not a community of people who are passive, who don't have ideas. And the challenge is how to bring together all of this intellectual, the brilliance of the people in our community, and their energy, and their excitement about moving forward to implement new ideas.

So we have put in place a lot of processes to engage a large part of the Harvard community. But not only the Harvard community, thinking about our neighboring institutions. And I'm not responsible so much for meeting with the cities and the regional governments. But another part of the office of the president and provost does do that.

To make this work, it's all about partnership. It's not about having a brilliant idea and then trying to get people to do it. It's drawing on everybody else's ideas.

ROBERT J. All right. One more, and then we close. What do you think is the biggest uncertainty facing the university?

BLENDON: ALAN M. Oh, how to choose one. GARBER:

ROBERT J. An economist should have no problem with this. BLENDON:

ALAN M. Well, since you said economist, you're probably thinking it's about financial uncertainty. And in fact, there is a GARBER: certain amount of truth to that.

But I would say that the biggest uncertainty has to be about how we position ourselves for the long term. And it's very easy for us to project forward one or two years and to extrapolate a short distance from where we are today.

We are a university that is approaching its 400th anniversary, the 400th anniversary of its founding. And we think in terms of centuries. Now, that doesn't mean I have an idea about how to position ourselves for two centuries from now. But we should be thinking very hard about what does it take to be a great university in 50 years.

How do we think about the research that we do. How do we think about the educational products we do. And how do we think about what's happening in the rest of the world, and how we relate to it. And we have a structure that I think has survived the test of time. But we still have to make bets.

It influences where we invest in terms of the faculty we recruit, new kinds of educational programs. You may think of those as relatively short term decisions, but we know things are slow to change. And we will be living with our decisions for a long time, probably much longer than people anticipate.

So I think a lot about the uncertainties of what we need to do for the future. University leadership thinks a lot about what's happening overseas. There are other models. We have faculty who are being recruited by research institutes in Europe where there's no teaching.

Are we going to lose some of our best researchers to those kinds of organizations down the road? How do we get people to feel that they are part of a great community here that's unlike any other? So the ultimate question for me and the source of uncertainty is how do we build a community and the infrastructure to support that community that will stand the test of time.

ROBERT J. So let me close with that challenge. My two hundred year vision is that somebody in this audience will be sitting BLENDON: here in the future playing this role. That's what this series has been about, is developing people, be able to see much more broadly the issues that we face. I think Dr. Garber did an extraordinary job, and we are very, very grateful. And I want to thank him again for being willing to do this.

ALAN M. Thank you, Bob. GARBER:

[APPLAUSE]

[MUSIC PLAYING]